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BUILDING. INSPECTOR RECORD
<br />SITE.WORK ID/SIG.COMMENTS ()\\NUR IttILI)tR t)EL( ARAl t(]N
<br />I hcrcby rfiion uMcr tf,nllly of p.llury rhd I m crcnll rn,n rh. Cs.rdos Li.ctre. bw ror rhc folloring casr (S(.1lll 5
<br />Ilunncss {ftI Profc$ion Codc): An} Ciry or County Bhi(h rcquncs a pc.mn Io cotrslrucl altcr. impnvc. d.nuni\h or Epat'any -
<br />idcfurc, rrin lo irs isuan.c. lko rcrtun s rhc aptlicunr tu such pcnr ro lilc a li8ncd ixrcnrnr rh.r h.or shc is li.cn{d pu6urnr
<br />ro lhr fmvisions ol lhc Cont,clols Liccn*d titr (Ch,Ircr 9, ComnrftinB Nirh Scction ?000 of Divhion :l olrhc B!\inc$ and
<br />PDlcsion\Codc) orihor trorshc t cxcq,t rficEtiomand rhc h!\h r'or rnc allcged eicnrflion Anyriolari.norsetn,nT0ll.5byuny-
<br />0!pli.dr ror a p.rmn subjccrs rh. {tli.,nr u , .ivil ,.tuhy ol nor
<br />'norc
<br />rhd nh hundr.d dollds ($50o)
<br />L .\ owmr of rhc pmlcny, or my c DkJy.cs wirh wlScs rs rhcir ek mmp.nqrnrn, will do rhc *oik aJld ttr (durc is rcl
<br />inrcntd or othrcd for sk ( SN 71x4. Busincsr ond Profcsions Colc Thc Co.tadols Licctrs tar dms not apdy ro an o*ncr or
<br />rh, OTlrny whbuildsditr bh! rkftn.,rxl wh. d{.s tuch solt hinsclfor h.r*lfor rhhugh his or h* osncnployccs.
<br />pmvidcd rtd sucn inDmrc.rnrs m mr ialcn& or olLEt lor st. li ho&ver. rhc huillioa or iqmEmnr k vrll] wirhin Dft ttr
<br />ofonplcio.. rh. owncr Buits will hnrc rh. bdrd.n or pnving thr h or shc dil d huild o. nnpm\r th. tolgly for rhc ,'!Tns o,
<br />,. x\ ownrroirhc rnr!.ny. rr cx.lu\ivclyconrr.i ng wirh li.cnsc ronirbnr. cotr(rucr rhc prct(r(Scc ?014. Bu{trcss
<br />i l laDlijsim Codc Thc Conrrrcu s t-i.cnsc Lrq d.cs ior rnfly t, n owncr ol pr)Fn y $h. huilds or nnpn,vcs r l[r.on.
<br />rid who coftacrr fitr \uch pmJc.rr wirhaco mck(n liccf\cd !trsurtrr hrhr c{ rnckr's l.iccn\cliw)
<br />I $cr.npr undcr Scrri
<br />TABtrESS:(AAIIENSAIION
<br />D!!I.ANAI[,N
<br />I h.ahy dfln'n undfi penrhyol |Erjrry onc ofrhc lnlk,win! d.clrrrri.ns
<br />lhtrk ndwillnuinrrinrCxnifirarcolConrtrruScllltr\urcrnrworkc^.onrN\rridr,r\frovidcdforbrScclior.lTlX)olrhc
<br />Ixhor(iic. tbrrhcp.rlonunu olrhc work forqhich rfu lcnnil i\ hsucd
<br />_,lrttand will mai iir sorkcn con!,ctrsorion iNur rcc. rs rcquncd bySecrhn 3?00olrhc ljhor Codc, for rhc rcnnntun.. or
<br />is hs8l. My u orkcr' onDcnsal ion iNur.Necrdd ul Fni.ynrnrhcr m:
<br />Z-\Zo\
<br />lccnilirhnr inlhc |xrturnr.ccofrhc wo fff $hich rhis!.rmir n i\sucd,I (h.lltrorutrl,)loy iny pcrsn in rny DutrNr
<br />$nsk,b.d,'rsu$ic.rt'rhcworkcr'.onr.nsirioDl.wso,(rlrliarir. d rlrco rhrr ill\lx'ul(l larom luhjc.r rothc
<br />sorlc^ conrrcnslion [ovi\ion\ ol'Sdiotr 37(Dollnc Lrhtr Codc.lshrll. ionhwirh rondy *irh rhxc rtuvisi(,ns
<br />WARNTNC Fnihrc b {.urc *(rkcn ..mpcnsdion h unlawful. and shall subiNi an cnlJ)loy.r ro sininnl rrBhiN Md
<br />ci\il llm! oj) b oN hu drcd rhuu\rid doll.n (Sl Fns.rion. &roEcr as pioridtd fd rhc
<br />s..rnr 1076.rrhc titxtr clxlc. ir crsr dnr
<br />-1. 10. [e
<br />ul:utltluu!
<br />c-7 ovvBzo
<br />7.
<br />AEITAXIDECI,A.EAIIAI
<br />I hor$y aJfinn undcr p€na]ry of Frjury onc ofrhe lollowins d(lardions:
<br />DcmolilnrPcflnih'Ast slos Noril-iculbnFcdelal Rc8uhrio.s(rnlc4.0, Pona)
<br />-Rcquncd
<br />Lctts o, Norilicolion
<br />!.cniryrhd lhc r.d.rd rcBxlrrionssgrdnrgrshc(osr.nx,vnlnrc mI {Dricabh ro rhk pmjccl
<br />-l
<br />ccnilyth.t I havc Ead rhh.ppli.alionandnatcthallhcuhrvc i.l'o.mlbn is.oBr I ngd t,6'nply *nh .ll Cny and Counly
<br />ordin!tucs and Sratc Laws rclarins ro hliliing consltucln,n. and hcrchy aurh,,n! qrc*nrarivcs (,rrht ciry and Coutrry ro cnlcr uF,n lhc
<br />ih)r nEnri rd l)rop. ylnrin
<br /> ppli{tri or la€tr1 sigmluro
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Subf IooriVenVl nsulation
<br />Rool Sheathi ng rlrzllE ..<4qtO ft[L t6:tz,' t..,'/,\r atu .
<br />Shear Wall Gu+ sn otz Rrk
<br />Framing . .4 nut sLztlla,*
<br />lnsulation/Energy I
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />[/lasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />En gineer Final Report
<br />Flood Zone Certif .
<br />FINAL 425//1 5N66
<br />Certif icate ol Occupancy
<br />Notes , Remarks, Etc.
<br />DATE
<br />Erection Pads
<br />Ih.toh,sfiound(FnrhyolpcrjurythrrIntli.cn$drlddrp!'vi\nnrofChaprag(coNncRin8wilhScdion?O0O)ofDivision]
<br />ol rhc lrusincs and Pmic$n'nr Codc...d mr ltcnsc i( ir tu ll ri,rcc Rl cliccr
<br />C-
<br />I
<br />CONIIf,IJqII!}NI.INDINCICENII
<br />I hcmhy ,m.n uMf Fialry ol pcrjury rhd rhdc is . coisrrucrinr lckling agcncy ior rhc !.rl'onMNc of rhc work for Nhich rhis td rir i\
<br />istrcd (Scc.309?.Cir. C )
<br />Lcn,lci. Nsnr.
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<br />trdcl' Addr.".
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